Advancing Family Medicine on Capitol Hill

Although partisanship currently seems to be affecting all aspects of health care policy, when family physicians visit the nation's capital for advocacy efforts they should avoid any sign of political posturing. That was the message delivered by several political consultants who spoke at the 2014 AAFP Family Medicine Congressional Conference here on April 7.

Attendees discussed the contentious issues of a permanent repeal of the Medicare sustainable growth rate (SGR) payment formula, changes in the field that occurred with implementation of the Patient Protection and Affordable Care Act (ACA), and graduate medical education (GME) challenges.

One of the authors of the ACA, Rep. Henry Waxman, D-Calif., noted the progress achieved with passage of the health care reform law. He pointed out that 7 million people have signed up for health insurance through the ACA-created marketplaces. Although the legislation remains a lightning rod for partisan debate, he reminded attendees that many of its major provisions include Republican or conservative proposals, such as the mandate requiring individuals to purchase insurance. It also includes some elements from former Sen. Bob Dole's proposal that served as the Republican alternative to President Clinton's outline of a health plan.

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When visiting Washington to advocate for family medicine, physicians should check their party loyalties at the door, according to speakers at the AAFP's Family Medicine Congressional Conference.

Teaching health centers show great promise for expanding GME for primary care physicians, but they need continued financial support from the government.

Waxman also noted that Congress was unable to pass a permanent repeal of the SGR in 2013 because members could not agree on how to pay for it. He said he does not expect a permanent fix would be addressed this year.

Following Waxman's presentation, a panel of experts discussed how the ACA has changed the Medicaid program. Speakers included Stephen Cha, M.D., M.H.S.R., chief medical officer for the Center for Medicaid and Children's Health Insurance Program Services at CMS; Kathleen Nolan, director of state policy and programs for the National Association of Medicaid Directors; and Kim Brandt, M.A., J.D., minority counsel for the Senate Finance Committee.

They noted that the federal government is testing a two-year increase in Medicaid payments to physicians that brings Medicaid payments up to at least Medicare levels. The goal of the initiative is to determine whether increasing these payments leads to increased access to primary care among lower-income individuals. The program, which is funded entirely by the federal government, is scheduled to end this year, and most states have reported that they cannot continue with the enhanced physician payments if federal dollars end.

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GME Issues

Conference speakers also addressed GME issues. They noted that a major contributing factor to the primary care shortage can be traced back to imbalances in the GME system. GME needs to move out of the hospital and into the field to meet community health needs, said speakers. Teaching hospitals operate under a different agenda because they seek residents who match with the hospital's particular specialty. As long as teaching hospitals continue to control GME, family medicine residences will be limited.

Fitzhugh Mullan, M.D., a professor of health policy at George Washington University, focused on the steady rise in medical school graduates and the disproportionately high rate of subspecialty medicine residencies. The number of medical school graduates has risen steadily since 2005 -- when it was 15,760 -- to the current figure of 18,156 for 2012-2013. The increase in medical school graduates is not improving the proportion of family physicians, however.

GME has become top-heavy and expensive, and it fails to meet the health care needs of surrounding communities. Mullan said that federal funding of residency slots is provided without conditions and greater accountability is needed in terms of where residents practice and whether they accept Medicare and Medicaid patients after they complete their training.

One positive element is the growth of teaching health centers. These dedicated primary care training centers are designed to provide care in underserved areas in rural or urban settings. In 2011, there were only 11 of these centers; there are now 44. The facilities were initiated as part of the ACA, but funding for the centers ends in 2015. A major discussion point was how to persuade Congress to extend the funding.

Preparing for the Hill

During the afternoon breakout session, attendees had an opportunity to practice their advocacy skills in simulated conversations with consultants to ready themselves for the following day's visits to legislators and staff. Julius Hobson, a government relations expert with the law firm Polsinelli, advised conference participants that they should discuss their needs with legislators in a neutral fashion without betraying their party affiliation. He noted that even when one party controlled all three branches of government, the SGR remained in place, despite strong opposition from physicians.

Stephanie Vance of Advocacy Associates led one simulation where she played the role of a busy Congresswoman shuttling between her office and the next committee meeting. Participants in her seminar were encouraged to introduce themselves, tell a personal story, relate the issue to the legislator and then make a request. In addition, she noted, policy advocates should not be discouraged to meet with congressional staff members because they can have a heavy influence on their legislators.

To close the first day of the two-day conference, AAFP members heard from Rep. Michelle Lujan Grisham, D-N.M. Grisham has experience working in the health care sector, having served as head of New Mexico's Agency on Aging and as head of the state's department of health.

She thanked attendees for their continued activism on the SGR issue, noting that Congress does not want to allow massive cuts to physicians as prescribed by the SGR formula. Access to medical care, especially in rural areas, needs to be increased, said Grisham, adding that primary care is at the forefront of efforts to increase such access.